Context

The Work Capability Assessment (WCA) is a process purported to determine whether a sick or disabled person has “limited capability to work”, which is required for a UK benefit claimant to continue receiving the Employment and Support Allowance (ESA). The process has been bitterly criticised by many who are in fact sick or disabled, and is subject to an annual “independent” review.

Some understanding of the process and criticisms that have been made can be found here and here.

The author of the 2013 review is Doctor Paul Litchfield, who has had a long and distinguished career connected with government and corporate initiatives on health care.

Summary

Boiled down even further from the Executive Summary, this is my impression of the gist of the review. I’ve tried to be reasonably fair and objective, but my prejudices may be showing through in places.

WCA is a functional assessment, not of the claimant’s diagnosis or condition, but of their ability to function.

This review can determine whether, following various changes, the WCA operates as intended. The length and complexity of the process makes people feel it’s unfair even if it isn’t, and some recommendations are made here to improve these perceptions. Improvements are also proposed with regard to mental health.

The DWP has made progress with the recommendations made by previous reviews. A major exercise on mental, intellectual and cognitive descriptors was not completed in time for this review. Properly evaluated pilots are important.

Key findings

The WCA is an effective way to assess eligibility for ESA, though the points score is somewhat arbitrary and can be distracting.

There is considerable dissatisfaction about the objectivity of the WCA. People need to be treated with respect and must understand the system better, particularly the roles of HCPs and DMs. The DWP needs to convey a clearer narrative with the assistance of the “nudge” unit.

Healthcare providers (HCP) are not sufficiently regarded as trusted advisers in decision making, by comparison with medical records. Treatment of cases identified as more or less complex may create a bias toward finding people unfit. More senior staff should see the borderline cases.

The WCA takes too long and can be improved, particularly by work with the BMA on the ESA113 medical report form.

Mental health is difficult to assess; medical diagnoses may not help in determining fitness [for work]. The ESA50 now asks for non-medical evidence on functional capability. DMs and HCPs need to be better informed and better trained.

Northern Ireland

The system in Northern Ireland is similar but smaller and therefore less complex. Previous recommendations, where relevant, have mostly been implemented. Mental health has an even higher profile.

Issues

I have not yet made it to page 102 of the report, so anything I have to say for now will be based on the Executive Summary.

The review goes so far as to conclude that the WCA is a “reasonable and pragmatic tool”. It does not concern itself with whether people found “fit for work” are actually fit for work, or with what kind of work they may be fit for, whether such work exists, or whether it would be a useful application of their resources and those of the State to require particular groups of people to seek work in particular circumstances; nor with the consequences for those who, having been deemed “fit for work”, cannot actually work in the real world.

It is largely assumed that if individuals have a poor impression of the WCA, that must be because the DWP has failed to communicate a sufficiently clear narrative; or at most, because it has failed to exhibit sufficient respect. The idea that the WCA might be seriously flawed or abused for cynically political purposes is nowhere in this conceptual landscape.

It must also be a humorous suggestion that the HCP (Atos Healthcare) should be regarded as a “trusted adviser”, even though the abuses and failures usually blamed on Atos plainly must result from the (overt and implicit) demands of the DWP rather than from any special malice or incompetence belonging to Atos themselves.

One has to wonder, even without regard to the concerns about Litchfield’s background expressed by DPAC below, whether this is a usefully independent and thorough review.

Responses

Disabled people face huge challenges when it comes to work, such as a lack of skills and experience, confidence and even negative attitudes from some employers. The Work Capability Assessment ignores all of this. It’s a tick-box test of someone’s medical condition.

Disabled people have lost all faith in this test.

[…]

The fitness-for-work test is broken. If the Government is serious about getting more disabled people into work, they need a test that is the start of the process that gives disabled people the specialist, tailored and flexible support they need.”

Dr Paul Litchfield […] was part of the Mental Health Technical Working Group commissioned by DWP in 2006, with, among others, Sue Godby from the College of Occupational Therapists and Unum Provident, and Dr Angela Graham from Atos Origin, to develop ‘proposals from transforming the Personal Capability Assessment (the forerunner to the WCA), from an incapacity-based tool for determining entitlement to Incapacity Benefit to a more positive assessment incorporating assessment of capability and of health related interventions which would contribute to overcoming health-related barriers preventing people with disabilities from engaging with work’.

There is little or no recognition by Dr. Litchfield of the widespread anger and criticism of the poor standard of medical assessments carried out by Atos Healthcare Professionals. Instead, he advises that DWP Decision Makers “view Atos HCPs as trusted advisers”.

Independent reviews are supposed to be just that. It is hard to understand how our findings can be so very different to those of the Mr Litchfield. We think that he and the government owe an explanation.

The Department for Work and Pensions (DWP) should restart publishing statistics showing the comparison between outcome at assessment, reconsideration and appeal stages to allow greater transparency and monitoring of the system.

The WCA has been criticised as producing harsh and unreasonable results that are often overturned on appeal – a lengthy process that must in itself deter many sick and disabled people – and which in the interim causes immense hardship and distress. The British press provides an unending supply of anecdotes about claimants who were deemed fit for work while very obviously unwell or disabled, and who in many cases died shortly after being assessed. A number of suicides has been connected with the WCA and its consequences.

Summary

This “evidence based review” was an attempt to measure the effectiveness of the existing Work Capability Assessment (WCA) as compared to an Alternative Assessment (AA)

600 ESA claimants were recruited (73% consent rate) when they attended a WCA at one of two centres. Participants were asked to cooperate with

a standard WCA with an observing “health care professional” (HCP) as well as the HCP conducting the assessment

an additional interview with only the observing HCP, to collect any extra details needed for the AA

in 250 cases, the assessment was repeated from paper evidence, “independently by another two HCPs”. It isn’t clear if these HCPs were independent of each other (2 further assessments per case) or only of the original assessment (1 further assessment per case). [Update:] That is, the papers were assessed twice more, once by each of two new and separate HCPs.

An additional set of criteria was devised by a panel of 90 experts and applied to the evidence collected in the WCA and AA interviews.

The AA tended to produce higher scores for limited capacity to work. Claimants preferred the AA; HCPs found the (partial) AA was useful though it’s not clear whether they preferred it. However, the expert panels tended to produce results nearer to the WCA than the AA. The paper reassessments were highly consistent for the WCA, but only moderately consistent for the AA.

Issues

Claimants arriving for a WCA were asked whether they wished to participate in the exercise. This might systematically exclude claimants whose health condition or other circumstances made this extended process difficult.

The examinations were conducted by Atos Healthcare. In view of various news reports it might be rash to assume good faith or appropriate diligence.

On the other hand, the claimants and HCPs were all aware that an exercise was being conducted and might be expected to be on their best behaviour. We would not expect this exercise to detect the effects of any deniable targets (or “norms”) that might be significant for WCA in normal conditions.

The WCA, the AA, and the expert panel criteria were all devised by individuals from a limited set of experts who may well subscribe to an industry-wide consensus on health issues as they relate to capability for work. These methods of assessment were compared with each other and tested for consistency. There was no comparison with any objective criteria, nor with actual health or employment outcomes. This exercise should not be understood as supporting or vindicating the WCA except in these very limited terms.

These connections likely give men an efficient system for coordinated action, where the cerebellum and cortex participate in bridging between perceptual experiences in the back of the brain, and action, in the front of the brain, according to the authors. The female connections likely facilitate integration of the analytic and sequential processing modes of the left hemisphere with the spatial, intuitive information processing modes of the right side.

It seems plausible that there is sexual dimorphism in the brain, though any interpretation of the functional consequences is likely to be simplistic – especially when the popularly misunderstoodlateralisation of function is invoked. The text of the article is $10 away, but neither the abstract nor the news release include any discussion of the extent or statistical significance of the dimorphism.

I’m hoping to see some more informed comments (than mine!) under the Neuroscience News coverage of this study.

They don’t say “bullied”, they say “helped”. We know from experience that when these people say “help” they mean sod all actual help, backed up with useless advice, bullying and punishment. The premise is that life is a bowl of cherries, if something has gone wrong for you then you must be a naughty person and should pull yourself together and be ashamed of yourself.

Nothing has been done, other than Tory joined-up “thinking”, to show that the 120,000 families with problems are the same people, or the same numbers of people, who might somehow deserve to be treated like this. Or that anyone deserves to be treated like this.

It would be nice if some of the people caught up in this get some benefit, and if the original 120,000 families – some of whom might even be the same people – don’t get entirely forgotten under the propaganda. It doesn’t appear that the government’s efforts are very likely to do this, or were seriously intended to do this.

Under what remains of the welfare state, people are today – this year and last year and next year – going hungry, being thrown out of their homes, forced to work however sick they are, and literally driven to despair and death.

But even that is too much for “Britain” to afford. What of the hungry, the homeless, the sick? Are we not “Britain” too?